Professional claim · CMS-1500 · EDI 837P
CLM-2026-010356
Canyon Primary Care Associates, Family Medicine. Service 2026-05-07 at office (POS 11). Received 2026-05-15.
Approved
Billed
$552.00
3 lines
Allowed
$342.24
contract rate applied
Plan pays
$302.24
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jeremy Sullivan
- Member ID
- UHC-15896-37
- Date of birth
- 1981-10-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421208
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3701
- Coverage period
- 2025-02-01 to present
- Deductible
- $2,186.00 of $2,500.0087%
- Out-of-pocket maximum
- $2,331.47 of $5,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4536468513
- Network
- In network
- Rendering NPI
- 5065603339
- Location
- Dallas, TX · TIN 25-8447887
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $270.00 | $167.40 | $40.00 | $127.40 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $35.00 | $21.70 | $0.00 | $21.70 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $247.00 | $153.14 | $0.00 | $153.14 | Paid |
| Totals | $552.00 | $342.24 | $40.00 | $302.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-216433
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030787 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-07: NULL (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (4536468513). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Primary Care Associates2026-05-07 09:10
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$552.00
Plan discount
$209.76
contracted rate
Plan paid
$302.24
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.